• Current Issue
• ACP Hospitalist Weekly
  • Archives
• Supplements
• Blog
• Archives
• Career Connection
• Subscribe
• RSS Feeds

ACP HospitalistWeekly

---

In the News for the Week of 11-16-11

---

Highlights

Tool helps stratify risk of patients with acute COPD exacerbations

Researchers successfully validated a tool that helps stratify risk of in-hospital death and mechanical ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) at the time they present to the hospital. More...

Hospitalists can help alleviate intensivist shortage, study suggests

There was no difference in adjusted mortality or length of stay between medical ICU patients cared for by a hospitalist-led versus an intensivist-led team, a new study found, though intermediate- and high-acuity mechanically ventilated patients may benefit from care by intensivists. More...

Antithrombotic therapy

Higher CHADS₂ scores can indicate higher risk in patients on anticoagulants

Higher CHADS₂ scores pointed to higher risk for adverse outcomes, including stroke, bleeding and death, in patients with atrial fibrillation receiving anticoagulation, according to a new study. More...

Mental health

Suicide rating scale offers insights into intent, actions of patients

A suicide assessment exam that quantifies suicidal ideation and suicidal behavior as distinct domains instead of a continuum of behavior is suitable for clinical use, a new study concluded. More...

FDA update

Rivaroxaban approved for atrial fibrillation

The anticoagulant rivaroxaban (Xarelto) was approved last week for a new indication—reducing the risk of stroke in patients who have non-valvular atrial fibrillation. More...

Cartoon caption contest

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner. More...

Physician editor: A. Scott Keller, MD, FACP

---

Highlights

---

.

Tool helps stratify risk of patients with acute COPD exacerbations

Researchers successfully validated a tool that helps stratify risk of in-hospital death and mechanical ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) at the time they present to the hospital.

Using 2007 data from a clinical research database, researchers analyzed 34,699 admissions to 177 U.S. hospitals of patients older than age 40 years with a principal diagnosis of AECOPD (81%) or acute respiratory failure with a secondary diagnosis of AECOPD (19%). Based on information available at hospital presentation, patients were put into one of five classes of the BAP-65 tool (BAP-65 criteria are blood urea nitrogen [BUN] ≥25 mg/dL, altered mental status, pulse >109 beats/min, and age >65 years). Patients with none of the first three criteria who were age 65 or younger were class I; those with no criteria who were older than age 65 were class II. Patients with one, two or three risk factors were class III, IV and V, respectively. Primary end points were hospital mortality and need for mechanical ventilation, while secondary end points were length of stay (LOS) and costs. The study results were published in the November Chest.

Mortality rates increased with rising BAP-65 class, from fewer than 1% of patients in class I to more than 25% of patients in class V (P<0.001). Need for mechanical ventilation also increased with class, from 2% in class I to 55% in class V (P<0.001). The area under the receiver-operating characteristic curve (AUROC) for BAP-65 for hospital mortality and/or need for mechanical ventilation was 0.79 (95% CI, 0.78 to 0.80). While the median LOS was four days, median LOS was only three days in class I patients and rose almost linearly to seven days in class V patients (P<0.001). Likewise, median costs for class I patients were $4,307 and rose to $11,473 for class V patients (P<0.001).

The current analysis expands on initial work on the BAP-65 tool by validating it in a large group of patients distinct from those in which it was developed, by including a population that had previously been excluded (those with a principal diagnosis of respiratory failure), and by measuring resource use (LOS and costs), the authors noted. An advantage of the BAP-65 is its objectivity, which means it can be applied with consistency, reliability and generalizability, the researchers concluded, while its information on LOS and cost can be used for economic risk stratification.

Top

.

Hospitalists can help alleviate intensivist shortage, study suggests

There was no difference in adjusted mortality or length of stay between medical ICU patients cared for by a hospitalist-led versus an intensivist-led team, a new study found, though intermediate- and high-acuity mechanically ventilated patients may benefit from care by intensivists.

In a prospective, observational study at an urban academic hospital, researchers compared 828 consecutive medical patients admitted to a hospitalist-led ICU team (with intensivist consultation/comanagement of 152 patients) with 528 patients admitted to an intensivist-led ICU teaching team. Assignment of patients to admitting teams followed existing referral patterns, meaning ED patients who required invasive ventilatory support were admitted to the intensivist-led team, as were those transferred from a hospital floor bed to the ICU by non-hospitalist physicians. Patients with respiratory failure requiring noninvasive ventilation were admitted to the hospitalist-led team, as were those transferred by hospitalist floor teams. Both teams participated in similar multidisciplinary rounds and used the same evidence-based protocols and order sets. (Patient assignment sometimes deviated based on ICU teams' census, however—intensivists had a strict limit of 20, while hospitalists had a preferred limit of 12.) Study results were published online Nov. 8 in the Journal of Hospital Medicine.

Patients admitted to hospitalists were more likely to have preexisting morbid obesity, while those admitted to intensivists more often had cancer, pulmonary disease and immunological disease (P≤0.05 for all). Hospitalist patients also had a significantly lower mean SAPS II (Simplified Acute Physiology Score), less use of noninvasive and mechanical ventilation, and fewer central venous catheters (P<0.001 for all). When adjusted for disease severity, in-hospital and ICU mortality rates didn't differ between teams, nor did adjusted length of stay (LOS). ICU readmission rates also were similar for both teams. In subgroup analysis, patients with intermediate illness severity who were on mechanical ventilation had lower hospital LOS (10.6 days vs. 17.8 days, P<0.001) and ICU LOS (7.2 vs. 10.6, P=0.02) in the intensivist-led group, as well as a trend toward lower in-hospital mortality (15.6% vs. 27.5%, P=0.10).

Study limitations include the single-center observational design and the fact that results may be more relevant to academic centers, the researchers noted. Patients assigned to the two teams also differed substantially in illness severity and mechanical ventilation; though researchers tried to control for this via statistical techniques, residual confounders may have remained, they noted. Also, the mortality outcomes represent in-hospital mortality, not 30-day mortality. Still, the study results are helpful in suggesting hospitalists can help alleviate the current shortage of intensivists by caring for lower acuity critical care patients, leaving intensivists to care for higher acuity patients—especially those that are mechanically ventilated, the authors concluded.

Top

---

Antithrombotic therapy

---

.

Higher CHADS₂ scores can indicate higher risk in patients on anticoagulants

Higher CHADS₂ scores pointed to higher risk for adverse outcomes, including stroke, bleeding and death, in patients with atrial fibrillation receiving anticoagulation, according to a new study.

Researchers performed a subgroup analysis of data from the RE-LY study, a randomized, controlled trial comparing dabigatran and warfarin in patients with atrial fibrillation, to determine the prognostic importance of CHADS₂ for predicting thrombotic and bleeding complications in this population. The 18,112 study patients were receiving dabigatran, 150 mg or 110 mg twice daily, or open-label warfarin. CHADS₂ score, which assigns 1 point each for congestive heart failure, hypertension, age at least 75 years and diabetes and 2 points for stroke, was assessed at baseline. The primary outcomes were stroke or systemic embolism, and the primary safety outcome was major bleeding. Secondary outcomes included intracranial hemorrhage, vascular death and total death. The results of the study, which was funded by Boehringer Ingelheim, appear in the Nov. 15 Annals of Internal Medicine.

Overall, 5,775 patients had a CHADS₂ score of 0 to 1, 6,455 patients had a score of 2, and 5,882 patients had a score of 3 to 6. The annual rate of stroke or systemic embolism was 0.93% in patients with a CHADS₂ score of 0 to 1, 1.22% in patients with a score of 2, and 2.24% in patients with a score of 3 to 6. Patients with higher CHADS₂ scores also had higher annual rates of major bleeding (2.26%, 3.11%, and 4.42%, respectively) and vascular mortality, including death from bleeding (1.35%, 2.39%, and 3.68%, respectively) (P<0.001 for all comparisons). Rates of all adverse outcomes increased in both the warfarin and dabigatran groups as CHADS₂ scores increased. Rates of stroke or systemic embolism were lower in patients taking 150 mg of dabigatran twice daily than in those taking warfarin, while rates of intracranial bleeding were lower in patients taking either dose of dabigatran than in those taking warfarin.

The authors cautioned that their study involved post hoc, exploratory analyses and that the levels of statistical significance must be interpreted carefully, among other limitations. However, they concluded that increasing CHADS₂ scores were associated with increased risk for adverse outcomes, including death, in patients with atrial fibrillation receiving anticoagulation.

Top

---

Mental health

---

.

Suicide rating scale offers insights into intent, actions of patients

A suicide assessment exam that quantifies suicidal ideation and suicidal behavior as distinct domains instead of a continuum of behavior is suitable for clinical use, a new study concluded.

The Columbia-Suicide Severity Rating Scale (C-SSRS) (available online ) was designed to quantify the severity of suicidal ideation and behavior. To assess C-SSRS's validity compared to other measures of suicidal ideation and behavior, as well as the exam's internal consistency, researchers applied data from three previous studies:

• a National Institute of Mental Health multisite study of 124 adolescents with a suicide attempt or interrupted attempt 90 days before enrollment;
• an industry-sponsored multisite, double blind, placebo-controlled, parallel-group, fixed-dose clinical trial to evaluate the efficacy of escitalopram relative to placebo in the treatment of major depressive disorder among 312 adolescents with a diagnosis of major depressive disorder; and
• a study funded by the American Foundation for Suicide Prevention that evaluated the identification and classification of recent suicide attempts and nonsuicidal self-injurious behavior among 237 adults who presented to an emergency department for psychiatric reasons.

Results were published online Nov. 8 by The American Journal of Psychiatry.

The authors found that the C-SSRS demonstrated good convergent and divergent validity with other suicidal ideation and behavior scales and had high sensitivity and specificity for suicidal behavior classifications compared with other assessment scales. Its ideation and behavior subscales were sensitive to change over time, the authors noted, and the intensity of ideation subscale demonstrated moderate to strong internal consistency.

Other important findings included the following:

• The C-SSRS severity subscale is sensitive to clinical change. Similarly, the C-SSRS identified almost an identical number of cases with specific types of suicidal behavior as the Columbia Suicide History Form and the suicide evaluation board ratings in study 1.
• The C-SSRS demonstrated predictive validity, while another scoring system for suicidal ideation did not predict near-term nonfatal suicidal behavior.
• A history of severe ideation with at least some intent to die may confer a greater risk for suicidal behavior than a history of ideation with no intent to die.
• The authors wrote, "The use of a standardized measure such as the C-SSRS that comprehensively assesses suicidal behavior and ideation permits comparison of findings across research and clinical populations, as well as trends over time, providing data to guide treatment recommendations for suicidal patients and suicide prevention efforts."

Top

---

FDA update

---

.

Rivaroxaban approved for atrial fibrillation

The anticoagulant rivaroxaban (Xarelto) was approved last week for a new indication—reducing the risk of stroke in patients who have non-valvular atrial fibrillation.

The safety and efficacy of rivaroxaban were evaluated in a clinical trial with more than 14,000 patients, in which it showed similar ability to warfarin in preventing stroke, according to an FDA announcement. Bleeding was the most common adverse event reported by patients in the trial. The risk of major bleeding associated with rivaroxaban was similar to that with warfarin; however, rivaroxaban caused less bleeding into the brain and more bleeding into the stomach and intestines.

On July 1, 2011, the FDA approved rivaroxaban to reduce the risk of blood clots, deep vein thrombosis, and pulmonary embolism following knee or hip replacement surgery. For atrial fibrillation, the drug should be taken one time a day with the evening meal so that it will be completely absorbed. Rivaroxaban carries a boxed warning to make clear that patients should not discontinue it before talking with their health care professional, as well as an FDA-required medication guide describing the risks and potential adverse reactions.

Top

---

Cartoon caption contest

---

.

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

"Medical homeless…will work for food."

"Hey lady, care to join my concierge practice?"

"My payor mix has got to change."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.

Top

---

About ACP HospitalistWeekly

ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP HospitalistWeekly, please click here.

Copyright © by American College of Physicians.

ACP JournalWise:
Reviews of the World's Top Medical Journals—FREE to ACP Members!

Learn on the Go with Internal Medicine 2012 Digital Presentations!

© ACP Hospitalist and American College of Physicians

ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated